ABDOMINAL WALL

HERNIAS
ABDOMINAL WALL HERNIAS

 Protrusion of a viscus or organ

through an opening in the wall of
the abdominal cavity
 As to Presentation: EXTERNAL,
INTERPARIETAL, OR INTERNAL
 As to Severity: REDUCIBLE,
IRREDUCIBLE (INCARCERATED),
& STRANGULATED.
 TAXIS – manual reduction of
hernia
ABDOMINAL WALL HERNIAS

 Common sites of Herniation:

 GROIN
 UMBILICUS
 LINEA ALBA
 SEMILUNAR LINE OF SPIEGHEL
 SURGICAL INCISIONS
 DIAPHRAGM
 Rare sites:
 PERINEUM, SUPERIOR LUMBAR TRIANGLE OF
GRYNFELTT, INFERIOR LUMBAR TRIANGLE OF
PETIT, OBTURATOR FORAMEN, AND SCIATIC
FORAMEN OF THE PELVIS
ABDOMINAL WALL HERNIAS

General Signs and Symptoms:

 Slowly enlarging reducible mass to the point
of becoming irreducible.
 Pain or discomfort when upright, relieved
when supine
 Incarcerated mass with tenderness, intestinal
obstruction, & sepsis
 Taxis is contraindicated when hernia is
strangulated
ABDOMINAL WALL HERNIAS

INDICATIONS FOR SURGERY:

 Diagnosis of a Hernia is an Indication of
Surgery
 Exception: Patient is not medically fit /
not safe to do surgery
ABDOMINAL WALL HERNIAS

GROIN HERNIAS
 most common site of
all abdominal
herniation
 men > women

 right > left

 Types:
 INGUINAL HERNIAS:
DIRECT OR INDIRECT
 FEMORAL HERNIA
 ABDOMINAL WALL HERNIAS
SURGICAL ANATOMY OF THE GROIN:
Review of important Anatomic
Structures:
 Oblique muscles and aponeurosis of
the abdomen
 Ilioinguinal, Iliohypogastric, and
Genital branch of the Genitofemoral
nerve
 Innermost Aponeuroticofascial Layer
of the Abdomen: Transversus
abdominis muscle, Transverse
aponeurosis, and Transveralis fascia
 Iliopubic Tract ( Transverse
aponeuroticofascial layer above the
femoral sheath / Deep crural arch /
Bandelette of Thompson )
 Cooper’s Endopelvic fascia ( Fascia
Transversalis )
 Cooper’s ligament ( Iliopectineal
ligament )
 Hesselbach’s Triangle
 Shutter Mechanism of the Internal
Oblique Muscle on the Deep ring
 Spermatic cord: coverings and
contents
 Inguinal Canal and its borders
ABDOMINAL WALL HERNIAS
ABDOMINAL WALL HERNIAS

FRUCHAUD’S MYOPECTINEAL
ORIFICE:
Borders:
 Superiorly – Internal oblique &
Transversus muscles
 Laterally – Iliopsoas muscle
 Inferiorly – Pecten pubis
 Medially – Rectus abdominis muscle
and sheath
 Area is protected only by the
Transversalis Fascia
 ABDOMINAL WALL HERNIAS
INDIRECT INGUINAL HERNIAS:
 most common type of inguinal
hernia in both males and
females
 congenital : Right side > Left
side
 due to a PATENT PROCESUS
VAGINALIS TESTIS
 80% newborns with patent
sac
 spontaneous closure
occurs until 2 years old
 20% patent procesus
vaginalis testis persist
among adults
 Aggravating factors: Erect
stance, Muscle deficiency,
destruction/ weakness of
connective tissues, chronic
↑ abdominal pressure
ABDOMINAL WALL HERNIAS

 Complete- Hernia extends

down to scrotum
 Incomplete- Hernia still along
inguinal area

SLIDING HERNIA:
retroperitoneal organs “slide”
into the sac and becomes part
of the wall of the sac
 Differentiate from a
HYDROCOELE
 Arises lateral to
Hesselbach’s Triangle
 ABDOMINAL WALL HERNIAS

DIRECT INGUINAL HERNIAS:

 Outward and forward protrusion

within Hesselbach’s Triangle
 Due to weakened inguinal floor
 Contained only by the External
Oblique aponeurosis
 Common in the Elderly & those with
Chronic ↑ Intraabdominal pressure
 No lateral predominance
 Usually a diffuse bulge involving the
whole floor of the inguinal canal
 Less risk of Incarceration /
Strangulation
 When combined with Indirect Inguinal
Hernia = PANTALOON HERNIA
 ABDOMINAL WALL HERNIAS
FEMORAL HERNIA:
 uncommon
 > in women ( multiparous )
 bulge below the inguinal ligament usually
incarcerated / strangulated
 right side > left side
 Differentiated from lymph nodes in the Femoral
canal : Node of Cloquet
 Requires urgent surgery
ABDOMINAL WALL HERNIAS

GROIN HERNIOPLASTY:
 2 MAIN TYPES OF REPAIR:
 ANTERIOR ( Classical )

 POSTERIOR ( Properitoneal )

 2 METHODS OF REPAIR:
 Direct Aponeurotic Closure of Myopectineal
Orifice
 Replacement of Defective Fascia Transversalis
with Synthetic Prosthesis (MESHED REPAIR)
 ABDOMINAL WALL HERNIAS

ANTERIOR GROIN HERNIOPLASTY:

3 Main Parts of the Repair:

 Dissection of the inguinal canal
 Repair of the Myopectineal Orifice
 Closure of Inguinal Canal
 ABDOMINAL WALL HERNIAS
Types of Repair:
 MARCY REPAIR:
 Tightening of enlarged deep ring
only
 BASSINI REPAIR:
 Approximation of conjoint tendon
to iliopubic tract and shelving edge
of inguinal ligament
 SHOULDICE-BASSINI REPAIR:
 Imbricated closure of innermost
aponeuroticofascial layer
 MC VAY REPAIR:
 Repair using Coopers ligament with
relaxing incisions at rectus sheath
 LICHTENSTEIN TENSION FREE
HERNIOPLASTY
 Meshed closure of inguinal floor
ABDOMINAL WALL HERNIAS
 ABDOMINAL WALL HERNIAS
POSTERIOR GROIN HERNIOPLASTY:
 Types of Repair:
 PROPERITONEAL PATCH PROSTHETIC REPAIR
 STOPPA PROCEDURE: Giant Prosthetic
Reinforcement of the Visceral Sac (GPRVS)
 LAPAROSCOPIC HERNIOPLASTY
 ABDOMINAL WALL HERNIAS
UMBILICAL HERNIA:
 Adult onset conditions:
 Predisposing factors: Obesity, Repeated
Pregnancies, Ascites, “Pot Belly”
 Hernias in Newborns are developmental
 Close spontaneously if defect is 1.5 cm. or
less within first 2 years
 Indication for surgery= if defect > 2cm or
persistent by age 3 or 4
 TREATMENT:
 Surgical : Classical “Vest-over-pants”
imbrication of superior and inferior
aponeurotic layers
 ABDOMINAL WALL HERNIAS

INCISIONAL HERNIAS:
 2 Principal Causes: Obesity and Infection
 EVANTRATION DISEASE:
 Respiratory dysfunction due to loss of integrity of the
abdominal wall that reduces intraabdominal pressure
 Causes “Paradoxical Respiration”

 Loss of right of domain by the viscera with shrinking of

abdominal wall cavity – Hernia reduction leads to Vena
Cava Compression and Respiratory Depression
 Spontaneous skin ulceration at hernia pouch
 ABDOMINAL WALL HERNIAS
TREATMENT:
 Incisional Hernioplasty
 Simple Closure for Small Defects ( < 10cm )

 Prosthetic Repair for Large and Recurrent

Hernias
 Mesh extend 8 – 10cm along lateral border of
defect
 Mesh extend 4 – 5 cm superiorly and inferiorly
ABDOMINAL WALL HERNIAS

EPIGASTRIC HERNIA:
 protrusion of properitoneal fat and peritoneum
through the linea alba between the Xyphoid
Process and the Umbilicus
 Repair similar to that of umbilical hernia
 ABDOMINAL WALL HERNIAS

SPIGELIAN HERNIA:
 A ventral hernia occurring at
the subumbilical portion of
Spiegel’s Semilunar line and
through Spiegel’s Fascia
 Small hernias are simply
closed; Larger ones require
prosthesis
 ABDOMINAL WALL HERNIAS
LUMBAR HERNIA:
 Gynfelt’s Superior Triangle : Borders: 12th
rib, internal oblique, sacrospinalis muscle
 Petit’s Inferior Triangle: Borders: latissimus
dorsi, external oblique, iliac crest
 Managed as Incisional Hernias
 ABDOMINAL WALL HERNIAS
PELVIC HERNIA:
 Hernias through the Obturator Fossa,
through the Greater and Lesser Sciatic
Foramen
 Most common is Obturator Hernia
 Almost always strangulated
 Howship-Romberg Sign: Pain at hip,
inner thigh and knee secondary to
Obturator nerve compression
 Preferrably repaired using Prosthesis
 ABDOMINAL WALL HERNIAS
PARASTOMAL HERNIAS:
 Paracolostomy Hernias more common than
Paraileostomy hernias
 When ostomy is created through the semilunar line is
instead of the rectus sheath
 Treatment:
 Traditional Method: Moving the stoma to a new location
 Local Repair: Leslie Procedure ( Meshed
Reinforcement )
ABDOMINAL WALL HERNIAS
ABDOMINAL WALL HERNIAS
Thank You!